Spinal Cord Injuries

I was reading a well known author when an interesting method of killing was proposed. His villain dislocated his victim's spinal cord manually by prying his fingers between the vertebrae. For that reason alone, I almost did an Author Beware post.Then, what followed was the victim living for a few hours paralyzed but still able to breathe. This is bridging on implausible and here's why.

First, regarding the method of incapacitating this character. Have you ever watched the TV show Wipeout? Our family loves it and it's generally clean (well... there is a lot of mud) fun and the participants often have some teeth-clenching falls where I've been surprised to see a them get up and actually walk away. The point being it that it is difficult to break your neck to the point of injuring your spinal cord. It takes a lot of force. Football players colliding. A serious car accident. Diving into a pool and landing directly on your head. So, visually for me, someone prying their fingers into the gap between the vertebrae (those gaps are small) limits the believability.

Second, let's assume the injury did happen as the author described. Could the character have been prone and alive for a couple of hours? Depends on their level of injury.

The first important thing as a medical person is to determine what level the spinal cord is injured at. Everything below the level of injury is impaired.



http://www.spinalinjury.net/

However, during the acute injury phase, things swell up. The swelling itself my cause impairment but the patient's level of function may improve once the swelling goes down. Two muscle groups help you breathe. First and foremost is the diaphragm. This is a thin layer of muscle that divides your chest and abdomen. It sits beneath your lungs. It is controlled at about C3-C5 (that's your cervical spine and is in the region of your neck). Next are your chest muscles. These are used less for breathing (unless a patient is having difficulty) and are controlled by your thoracic spine which is your upper back.

For this character having a spinal cord injury in the upper neck with subsequent swelling makes me doubtful he would have lived a couple of hours without intervention. Consider carefully level of spinal cord injury and how it will effect your character's good health.

Have you written a scene incorporating a spinal cord injury?

Author Beware: Wrong Medical Procedure

Recently, I was reading a novel by a well-known published author. I'm enjoying the story line a lot which is preventing me from putting the book down and reading another one.

This was the written sentence. "We took him to the OR and drilled a hole in his head just in case there was a subdural hematoma."

WOW! There's a lot going on in this single sentence. A lot that is medically inaccurate and I'll tell you why.

First, a subdural hematoma is a "collection of blood on the surface of the brain"-- between the brain and the skull.  The volumes of this blood collection vary and do not always need intervention. However, if the volume of the blood collection is large enough, it can actually push on the brain and cause its contents to shift. This is termed herniation. In that case, surgical evacuation of the blood clot by a neurosurgeon is the preferred treatment.

Drilling a hole in a patient's head is generally done for two reasons. The first is to drain cerebrospinal fluid and the second is to monitor intracranial pressure or ICP. So, even if the patient did have a subdural hematoma, this likely would not be therapeutic treatment.

The next issue is the just in case part. With CT scanning readily available (even at most smaller hospitals), there should be no reason to wonder whether or not the patient has a subdural. This particular patient took a severe beating to his head and has neurological deficits. Standard treatment would be to do a CT of his head. Then the medical staff would know for sure what they were dealing with.

Which leads us to the last issue. The doctor performing the surgery was an orthopedic surgeon. This is not in their realm of specialty. Drilling a hole in someone's head goes to the neurosurgeon. I can't think of many ortho types who want to be mucking around near the brain. And if they are, they've likely consulted a neurosurgeon.

Scope of practice issues come up commonly in manuscripts. Either the act done is outside that character's scope of practice. For example, an EMT performing a C-section is outside their scope of practice. Or, a specialist is doing something they usually don't do as in this case.

To be clear, I do think it is okay that a fictional character does something they're not supposed to do like operating outside of their scope of practice. This can add great tension and conflict to a scene. Imagine an EMT attempting to do a C-section to save a baby's life when the mother has died. What I would be sure to do is make it clear that the character knows this is outside their scope and is troubled by doing it or maybe cavalier about doing it but that they know where the line is.

You can also take the other bend, the character doesn't know and does it anyway. In this instance, there should be discussion from other characters that this person is known for operating outside their scope and presents a danger to patients. Then, your reader will know that your medical knowledge is good but it is the character running amok.

What do you think? How would you have a character do something outside their norm that won't turn off your reader?

Author Beware: Arterial Bleeding vs. Venous Bleeding

I'm going to start doing these "Author Beware" posts every now and then. When you see that heading, it signals I'm doing a post on something a published author has written that medically is questionable. Now, I won't name the author or book, just the situation. So, if you know the book and/or author, please keep it close to the vest. This is merely for learning purposes.


geology.com

In two novels recently, I've come across inaccurate descriptions of venous versus arterial bleeding. One novel in which a character had slit his wrists clearly described arterial bleeding but called in venous bleeding. Another novel described a puncture wound to the neck and a "geyser" of blood from the wound yet the character made it to the hospital with a dressing around his neck.

First, what is the difference between arterial and venous bleeding? A short anatomy lesson first. Arteries are on the forward side meaning this is blood that has just left the heart. In order for your heart to get blood through the body, it has to pump. The heart's pumping is something you can feel... it's called your pulse. Whereever you feel your pulse is an artery.

Venous blood is on the return side. This is blood that has off loaded its oxygen and is on its way back to the lungs. There's not as much pressure, per se, in those vessels.

When you puncture an artery, it spurts, pretty dramatically, with each heartbeat. I saw a demonstration once of how long it would take someone to "bleed out" from an untreated arterial bleed to the knee which houses the popliteal artery. Now compared to some, this would be a smaller sized artery compared to your aorta. Any guesses?

About three minutes.

Venous bleeding doesn't have the characteristic spurting with each heartbeat. It generally oozes though it can ooze quite a bit. Venous bleeding can also be deadly if there is enough of it left untreated.

Arterial bleeding is generally harder to control than venous bleeding. You have to apply a lot of pressure to get it to stop. Hence, my dismay at how a character who sustained an injury to his neck, likely the carotid artery, could have made it to the hospital with a simple dressing in place.

What do you think?

Drug Abuse in America: Part 3/3

Is there a prescription drug abuse problem in America? If so, what is the scope?

This ABC News piece aired in April and it has been on my mind ever since. Here's a few of the stats that made my jaw drop.

Americans use 80% of all prescription pain killers in the world. The US consumes 99% of all Vicodin manufactured. In 17 states, deaths related to accidental overdose outnumber those deaths caused by motor vehicle accidents. Check out the full story at this link:
http://abcnews.go.com/US/prescription-painkillers-record-number-americans-pain-medication/story?id=13421828

Yes, I think there is a huge prescription drug problem here. There are also some disturbing trends/thoughts I'm concerned about. Should "emotional" pain be treated with narcotics. I say no. There is a purpose for sadness and grief. Why medicate with opiates? Is it not a better answer to work through the emotional pain rather than to numb it?

We are seeing more kids present to the ED within the last two years with complaints of migraine headache, chronic abdominal pain and back pain. We typically don't treat with narcotics. My guess is that eventually, if these children keep presenting with these complaints, someone along the way will give them some. Is that a good answer?

I think it's time that doctors institute tougher measures when prescribing narcotics just like the trend has swayed with overuse of antibiotics. This ABC news piece suggests to only give out pain killers for terminal illnesses. Broken bone, dental visit... only Ibuprofen for you.

What do you think about this issue? Give the narcotics or take a tougher stand? When should narcotics be given? Have you written about this in a fiction piece?

I'd love to hear your thoughts.